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Greene KA, Gelfand AA, Larry Charleston. Evidence-based review and frontiers of migraine therapy. Neurogastroenterol Motil 2024:e14899. [PMID: 39133210 DOI: 10.1111/nmo.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is identified as one of the "episodic syndromes that may be associated with migraine," along with benign paroxysmal torticollis, benign paroxysmal vertigo, and abdominal migraine. It has been proposed that CVS and migraine may share pathophysiologic mechanisms of hypothalamic activation and altered dopaminergic signaling, and impaired sensorimotor intrinsic connectivity. The past decade has brought groundbreaking advances in the treatment of migraine and other headache disorders. While many of these therapies have yet to be studied in episodic syndromes associated with migraine including CVS and abdominal migraine, the potential shared pathophysiology among these conditions suggests that use of migraine-specific treatments may have a beneficial role even in those for whom headache is not the primary symptom. PURPOSE This manuscript highlights newer therapies in migraine. Calcitonin gene-related peptide (CGRP) and its relation to migraine pathophysiology and the therapies that target the CGRP pathway, as well as a 5HT1F receptor agonist and neuromodulation devices used to treat migraine are briefly discussed as they may potentially prove to be useful in the future treatment of CVS.
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Affiliation(s)
- Kaitlin A Greene
- Division of Pediatric Neurology, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy A Gelfand
- Child and Adolescent Headache Program, University of California, San Francisco, California, USA
| | - Larry Charleston
- Department of Neurology and Ophthalmology, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
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Li H, Xu X, Xu R, Fan PX, Zhou J, Dong L. Latent class analysis of migraine associated vestibular-auditory symptoms. Cephalalgia 2024; 44:3331024241262488. [PMID: 38887813 DOI: 10.1177/03331024241262488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVE This study aimed to identify the potential subgroups of migraines based on the patterns of migraine associated symptoms, vestibular and auditory symptoms using latent class analysis and to explore their characteristics. METHOD A total of 555 patients with migraine participated in the study. Symptoms such as nausea, vomiting, photophobia, phonophobia, osmophobia, visual symptoms, vestibular symptoms (dizziness, vertigo), and auditory symptoms (tinnitus, hearing loss, aural fullness) were assessed. Latent class analysis was performed to identify subgroups of migraines. Covariates such as gender, age of migraine onset, frequency of migraine attacks per month, and family history were also considered. RESULTS The analysis revealed four latent classes: the Prominent Vestibular; Prominent Nausea; Presenting Symptoms but not prominent or dominant; and Sensory Hypersensitivity groups. Various covariates, such as gender, age of migraine onset, and frequency of migraine attacks, demonstrated significant differences among the four groups. The Sensory Hypersensitivity group showed the presence of multiple sensory symptoms, earlier age of migraine onset, and higher proportion of females. The Prominent Vestibular group had the highest probability of dizziness or vertigo but lacked the presence of auditory symptoms. The Prominent Nausea group exhibited prominent nausea. The Presenting Symptoms but not prominent or dominant group comprised individuals with the highest migraine attacks per month and proportion of chronic migraine. CONCLUSION This study identifies four subgroups of migraines based on the patterns of symptoms. The findings suggest potential different but overlapped mechanisms behind the vestibular and auditory symptoms of migraine. Considering the different patterns of migraine-related symptoms may provide deeper insights for patients' prognosis and clinical decision-making.
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Affiliation(s)
- Hui Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
| | - Xiaonuo Xu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
| | - Rongjiang Xu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
| | - Ping Xiao Fan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
| | - Jiying Zhou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
| | - Liang Dong
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University Department of Neurology, Chongqing, China
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Barbanti P, Aurilia C, Egeo G, Proietti S, D'Onofrio F, Torelli P, Aguggia M, Bertuzzo D, Finocchi C, Trimboli M, Cevoli S, Fiorentini G, Orlando B, Zucco M, Di Clemente L, Cetta I, Colombo B, di Poggio MLB, Favoni V, Grazzi L, Salerno A, Carnevale A, Robotti M, Frediani F, Altamura C, Filippi M, Vernieri F, Bonassi S. Ultra-late response (> 24 weeks) to anti-CGRP monoclonal antibodies in migraine: a multicenter, prospective, observational study. J Neurol 2024; 271:2434-2443. [PMID: 38231271 PMCID: PMC11055785 DOI: 10.1007/s00415-023-12103-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Nearly 60% of migraine patients treated with monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway experience a ≥ 50% reduction in monthly migraine days (MMD) at 12 weeks compared to baseline (responders). However, approximately half of the patients not responding to anti-CGRP mAbs ≤ 12 weeks do respond ≤ 24 weeks (late responders). We assessed frequency and characteristics of patients responding to anti-CGRP mAbs only > 24 weeks (ultra-late responders). METHODS In this multicenter (n = 16), prospective, observational, real-life study, we enrolled all consecutive adults affected by high-frequency episodic migraine (HFEM: ≥ 8 days/month) or chronic migraine (CM), with ≥ 3 prior therapeutic failures, treated with any anti-CGRP mAbs for ≥ 48 weeks. We defined responders patients with a ≥ 50% response rate ≤ 12 weeks, late responders those with a ≥ 50% response rate ≤ 24 weeks, and ultra-late responders those achieving a ≥ 50% response only > 24 weeks. RESULTS A total of 572 migraine patients completed ≥ 48 weeks of anti-CGRP mAbs treatment. Responders accounted for 60.5% (346/572), late responders for 15% (86/572), and ultra-late responders for 15.7% (90/572). Among ultra-late responders, 7.3% (42/572) maintained the ≥ 50% response rate across all subsequent time intervals (weeks 28, 32, 36, 40, 44, and 48) and were considered persistent ultra-late responders, while 8.4% (48/572) missed the ≥ 50% response rate at ≥ 1 subsequent time interval and were classified as fluctuating ultra-late responders. Fifty patients (8.7%) did not respond at any time interval ≤ 48 weeks. Ultra-late responders differed from responders for higher BMI (p = 0.033), longer duration of medication overuse (p < 0.001), lower NRS (p = 0.017) and HIT-6 scores (p = 0.002), higher frequency of dopaminergic symptoms (p = 0.002), less common unilateral pain-either alone (p = 0.010) or in combination with UAS (p = 0.023), allodynia (p = 0.043), or UAS and allodynia (p = 0.012)-a higher number of comorbidities (p = 0.012), psychiatric comorbidities (p = 0.010) and a higher proportion of patients with ≥ 1 comorbidity (p = 0.020). CONCLUSION Two-thirds of patients not responding to anti-CGRP mAbs ≤ 24 weeks do respond later, while non-responders ≤ 48 weeks are quite rare (8.7%). These findings suggest to rethink the duration of migraine prophylaxis and the definition of resistant and refractory migraine, currently based on the response after 2-3 months of treatment.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy.
- San Raffaele University, Rome, Italy.
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy.
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Stefania Proietti
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, Rome, Italy
| | - Florindo D'Onofrio
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | - Paola Torelli
- Unit of Neurology, Department of Medicine and Surgery, Headache Center, University of Parma, Parma, Italy
| | | | | | - Cinzia Finocchi
- Divisione di Neurologia, Ospedale San Paolo, ASL 2 Savonese, Savona, Italy
| | | | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giulia Fiorentini
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Bianca Orlando
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via Della Pisana 235, 00163, Rome, Italy
| | - Maurizio Zucco
- Headache Center, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Ilaria Cetta
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Valentina Favoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione, IRCCS Istituto Neurologico"Carlo Besta", Milan, Italy
| | - Antonio Salerno
- Headache Center San Giovanni Addolorata Hospital, Rome, Italy
| | | | | | | | - Claudia Altamura
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Stefano Bonassi
- San Raffaele University, Rome, Italy
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
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Baranoglu Kilinc Y, Torun IE, Kilinc E. D2 dopamine receptor-mediated mechanisms of dopaminergic system modulation in in vivo and in vitro experimental models of migraine. Eur J Neurosci 2024; 59:1177-1193. [PMID: 37539658 DOI: 10.1111/ejn.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
The dopaminergic system is implicated in the pathophysiology of migraine. However, the underlying mechanisms remain unclear. We explored the effects and mechanisms of dopaminergic system modulation in the in vivo and in vitro rat models of migraine. Dopaminergic agonist apomorphine, D2 receptor antagonists metoclopramide and haloperidol and 5-HT3 receptor antagonist ondansetron alone and together were tested in nitroglycerin-induced migraine model, in vivo. Likewise, the combinations of drugs were also tested on basal calcitonin gene-related peptide (CGRP) release in vitro hemiskull preparations. Mechanical allodynia was tested by von Frey filaments. CGRP concentrations in trigeminovascular structures and in vitro superfusates and c-Fos levels in the brainstem were determined by enzyme-linked immunosorbent assay. Meningeal mast cells were evaluated with toluidine blue staining. Apomorphine further enhanced nitroglycerin-induced mechanical allodynia, brainstem c-fos expression, trigeminal ganglion and brainstem CGRP concentrations and meningeal mast cell degranulation, in vivo. Haloperidol completely antagonised all apomorphine-induced effects and also alleviated changes induced by nitroglycerin without apomorphine. Metoclopramide and ondansetron partially attenuated apomorphine- or nitroglycerin-induced effects. A combination of haloperidol and ondansetron decreased basal CGRP release, in vitro, whereas the other administrations were ineffective. Apomorphine-mediated dopaminergic activation exacerbated nitroglycerin-stimulated nociceptive reactions by further enhancing c-fos expression, CGRP release and mast cell degranulation in strategical structures associated with migraine pain. Metoclopramide partially attenuated the effects of apomorphine, most likely because it is also a 5-HT3 receptor antagonist. Haloperidol with pure D2 receptor antagonism feature appears to be more effective than metoclopramide in reducing migraine-related parameters in dopaminergic activation- and/or NTG-induced migraine-like conditions.
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Affiliation(s)
| | - Ibrahim Ethem Torun
- Department of Physiology, Medical School, University of Bolu Abant Izzet Baysal, Bolu, Turkey
| | - Erkan Kilinc
- Department of Physiology, Medical School, University of Bolu Abant Izzet Baysal, Bolu, Turkey
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Dermitzakis EV, Vikelis M, Xiromerisiou G, Rallis D, Soldatos P, Litsardopoulos P, Rikos D, Argyriou AA. Nine-Month Continuous Fremanezumab Prophylaxis on the Response to Triptans and Also on the Incidence of Triggers, Hypersensitivity and Prodromal Symptoms of Patients with High-Frequency Episodic Migraine. J Clin Med 2024; 13:386. [PMID: 38256516 PMCID: PMC10816996 DOI: 10.3390/jcm13020386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Objective: To investigate whether the incidence of triggers, prodromal symptoms, hypersensitivity symptoms accompanying headache and responses to triptans were modified during a continuous 9-month fremanezumab therapy for migraine prophylaxis. Patients and methods: We studied 63 patients with high-frequency episodic migraine (HFEM). Enrolled patients received fremanezumab for nine consecutive months before defining the response rates and being stratified into treatment responders (≥50-74% reduction in monthly headache days (MHDs)), super responders (≥75%), partial non-responders (<50%) and super non-responders (<30%). Through headache diaries, patients provided data in order to document the impact of fremanezumab on the incidence of triggers, associated symptoms followed by headache and response to triptans (the use of the migraine treatment optimization questionnaire-4 (mTOQ-4)) during the 9-month treatment period. Results: Fremanezumab had early (after 3 monthly cycles) beneficial effects on the response to triptans in the majority of responders with relevant increases in mTOQ-4 scoring, but also in half of partial non-responders. A significant reduction in median days with migraine-associated symptoms was seen in responders after 6 months of therapy with fremanezumab, mostly for osmophobia, photophobia, phonophobia and nausea/vomiting, but partial non-responders also benefited. Likewise, the incidence of self-reported prodromal symptoms was significantly reduced in responders and was modestly diminished in partial non-responders. Triggers remained unaffected in both responders and non-responders. Conclusions: Fremanezumab given for at least 6-9 months may exert neuromodulatory effects in the migraine brain. These effects could result both in the inhibition of migraine chronification, but also in the diminishing of the magnitude of migraine-associated symptoms, mostly in responders and in partial non-responders.
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Affiliation(s)
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Athens, Greece;
| | - Georgia Xiromerisiou
- Department of Neurology, University Hospital of Larissa, University of Thessaly, 41110 Larissa, Greece;
| | - Dimitrios Rallis
- Department of Neurology, Tzaneio General Hospital of Piraeus, 18536 Athens, Greece;
| | | | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
| | | | - Andreas A. Argyriou
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
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Meşe Pekdemir E, Tanik N. Clinical significance of osmophobia and its effect on quality of life in people with migraine. Acta Neurol Belg 2023; 123:1747-1755. [PMID: 35864435 DOI: 10.1007/s13760-022-02030-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/10/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In this study, we aimed to evaluate the clinical significance of osmophobia and its effect on quality of life in people with migraine. METHODS A total of 145 people with migraine were included in this cross-sectional study. Patients were evaluated with the migraine data form, the Migraine 24-Hour Quality of Life Questionnaire (24-HrMQoLQ), the Migraine Disability Assessment Scale (MIDAS), the Patient Health Questionnaire-9 (PHQ-9), the Insomnia Severity Index (ISI), the Generalized Anxiety Disorder-7 (GAD-7), the Allodynia Symptom Checklist (ASC), and the Fatigue Severity Scale (FSS). To evaluate the presence of osmophobia retrospectively, a semi-structured interview was conducted with the patients by the neurologist. RESULTS The mean 24-Hr-MQoLQ of patients with osmophobia was significantly lower than those without osmophobia. The decrease in the 24-Hr-MQoLQ was statistically significant in the areas of feeling and concerns and social functionality. The mean of the MIDAS scale was higher significantly in patients with osmophobia than those without osmophobia. In addition, the mean ISI, PHQ-9, FSS and ASC scores of patients with osmophobia were statistically significantly higher than those without osmophobia. CONCLUSIONS Both 24-h and 3-month quality of life of people with migraine with osmophobia were more affected than those without osmophobia. At the same manner, insomnia, depression, fatigue and allodynia were observed at higher rates in people with migraine with osmophobia than in migraine without osmophobia. Osmophobia, which is one of the specific symptoms that distinguishes migraine from other headache disorders, deserves further and multifaceted investigation.
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Affiliation(s)
| | - Nermin Tanik
- Yozgat Bozok University Medical School, Yozgat, Turkey
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Duo L, Yu X, Hu R, Duan X, Zhou J, Wang K. Sleep disorders in chronic pain and its neurochemical mechanisms: a narrative review. Front Psychiatry 2023; 14:1157790. [PMID: 37324825 PMCID: PMC10267346 DOI: 10.3389/fpsyt.2023.1157790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Chronic pain (CP) is a prevalent problem, and more than half of patients with CP have sleep disorders. CP comorbidity with sleep disorders imposes immense suffering and seriously affects the patient's quality of life, which is a challenging issue encountered by clinicians. Although the reciprocal interactions between pain and sleep have been studied to some degree, there is still a lack of awareness and comprehensive description of CP comorbidity with sleep disorders. In this narrative review article, we summarize the current knowledge about the present estimates of the prevalence of comorbid sleep disorders in CP patients, sleep detection methods, sleep characterization in CP, and the effect of sleep disorders on CP and current therapies. We also summarize current knowledge of the neurochemical mechanisms of CP comorbidity with sleep disorders. In conclusion, insufficient attention has been paid to the role of sleep disorders in CP patients, and CP patients should be screened for sleep disorders in the clinic. Special attention should be given to a possible risk of drug-drug interaction when using two types of drugs targeting pain and sleep simultaneously. The current insight into the neurobiological mechanisms underlying CP comorbidity with sleep disorders is still rather limited.
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Li W, Liu R, Liu W, Li G, Chen C. The effect of topiramate versus flunarizine on the non-headache symptoms of migraine. Int J Neurosci 2023; 133:19-25. [PMID: 33499714 DOI: 10.1080/00207454.2021.1881091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To investigate the impact of topiramate versus flunarizine on the non-headache symptoms (NHS) of migraine, and to observe the changes of dopamine (DA) and prolactin (PRL) before and after prophylactic treatment. METHODS Sixty-six episodic migraine patients were enrolled and randomized 1:1 to receive either flunarizine or topiramate treatment. Clinical characteristics and NHS associated with migraine were investigated before and after prophylactic treatment. The DA and PRL levels were also determined before and after prophylactic treatment. RESULTS The NHS of migraine in the two groups were significantly better after treatment than before treatment in premonitory phase (PP), headache phase (HP), and resolution phase (RP). The NHS in the two groups had no significant difference in PP, HP, and RP before and after treatment. In the flunarizine group, the PRL content after treatment was significantly higher than that before treatment (t = -4.097, p < 0.001), but the DA content was decreased slightly compared with that before treatment (t = 1.909, p = 0.066). There was no significant difference in PRL content (t = 1.099, p = 0.280) and DA content (t = 1.556, p = 0.130) in topiramate group before and after treatment. CONCLUSIONS The two classical prophylactic drugs of migraine were significantly effective in treating the NHS of migraine, but there was no significant difference between the two drugs. The DA-PRL axis may be involved in the underlying mechanism of the flunarizine treatment for the NHS of migraine.
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Affiliation(s)
- Wei Li
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng, Shandong Province, China
| | - Ruiting Liu
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, Shandong Province, China
| | - Weidong Liu
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng, Shandong Province, China
| | - Guolei Li
- Department of Neurology, Liaocheng Third People's Hospital, Liaocheng, Shandong Province, China
| | - Chunfu Chen
- Department of Neurology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Neurology, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Barbanti P, Egeo G, Aurilia C, Altamura C, d'Onofrio F, Finocchi C, Albanese M, Aguggia M, Rao R, Zucco M, Frediani F, Filippi M, Messina R, Cevoli S, Carnevale A, Fiorentini G, Messina S, Bono F, Torelli P, Proietti S, Bonassi S, Vernieri F. Predictors of response to anti-CGRP monoclonal antibodies: a 24-week, multicenter, prospective study on 864 migraine patients. J Headache Pain 2022; 23:138. [PMID: 36316648 PMCID: PMC9623966 DOI: 10.1186/s10194-022-01498-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/26/2022] [Indexed: 11/07/2022] Open
Abstract
Background and objectives The identification of predictors of response to antiCGRP mAbs could favor tailored therapies and personalized treatment plans. This study is aimed at investigating predictors of ≥ 50%, ≥ 75% and 100% response at 24 weeks in patients with high-frequency episodic (HFEM: 8–14 days/month) or chronic migraine (CM). Methods This is a large, multicenter, cohort, real-life study. We considered all consecutive adult patients affected by HFEM or CM who were prescribed antiCGRP mAbs for ≥ 24 weeks in 20 headache centers. Patients were interviewed face-to-face using a shared semi-structured questionnaire carefully exploring socio-demographic and clinical characteristics. Patients received subcutaneous erenumab (70 mg or140 mg, monthly), galcanezumab (120 mg monthly, following a 240 mg loading dose), or fremanezumab (225 mg, monthly or 675 mg, quarterly) according to drug market availability, physician’s choice, or patient’s preference. The primary endpoint of the study was the assessment of ≥ 50% response predictors at 24 weeks. Secondary endpoints included ≥ 75% and 100% response predictors at 24 weeks. Results Eight hundred sixty-four migraine patients had been treated with antiCGRP mAbs for ≥ 24 weeks (erenumab: 639 pts; galcanezumab: 173 pts; fremanezumab: 55 pts). The ≥50% response (primary endpoint) in HFEM was positively associated with unilateral pain (UP) + unilateral cranial autonomic symptoms (UAs) (OR:4.23, 95%CI:1.57–11.4; p = 0.004), while in CM was positively associated with UAs (OR:1.49, 95%CI:1.05–2.11; p = 0.026), UP + UAs (OR:1.90, 95%CI:1.15–3.16; p = 0.012), UP + allodynia (OR:1.71, 95%CI:1.04–2.83; p = 0.034), and negatively associated with obesity (OR:0.21, 95%CI:0.07–0.64; p = 0.006). The 75% response (secondary endpoint) was positively associated with UP + UAs in HFEM (OR:3.44, 95%CI:1.42–8.31; p = 0.006) and with UP + UAs (OR:1.78, 95%CI:1.14–2.80; p = 0.012) and UP + allodynia (OR:1.92, 95%CI:1.22–3.06; p = 0.005) in CM. No predictor of 100% response emerged in patients with HFEM or CM. Conclusions A critical evaluation of headache characteristics indicating peripheral or central sensitization may help in predicting responsiveness to antiCGRP mAbs in HFEM and CM. A more precise pain profiling may represent a steppingstone for a mechanism-based approach and personalized treatment of migraine with compounds targeting specific molecular mechanisms.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via della Pisana 235, 00163, Rome, Italy. .,San Raffaele University, Rome, Italy.
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via della Pisana 235, 00163, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via della Pisana 235, 00163, Rome, Italy
| | - Claudia Altamura
- Headache and Neurosonology Unit, Headache and Neurosonology Unit, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | | | | | - Maria Albanese
- Regional Referral Headache Center, Neurology Unit, University Hospital Tor Vergata, Rome, Italy
| | - Marco Aguggia
- Neurology and Stroke Unit, Asti Hospital, Asti, Italy
| | - Renata Rao
- Departement of Neurological Sciences and of Vision, P.le Spedali Civili, Brescia, Italy
| | - Maurizio Zucco
- Headache Center, Neurology Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Massimo Filippi
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Unit, Headache Center, Vita-Salute San Raffaele University and San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Messina
- Neurology Unit, Neurorehabilitation Unit, Neurophysiology Unit, Headache Center, Vita-Salute San Raffaele University and San Raffaele Scientific Institute, Milan, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Antonio Carnevale
- Headache Center, Neurology Unit, San Filippo Neri Hospital, Rome, Italy
| | - Giulia Fiorentini
- Headache and Pain Unit, IRCCS San Raffaele Roma, Via della Pisana 235, 00163, Rome, Italy
| | - Stefano Messina
- Department of Neurology-Stroke Unit, Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Paola Torelli
- Unit of Neurology, Department of Medicine and Surgery, Headache Center, University of Parma, Parma, Italy
| | - Stefania Proietti
- Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, Rome, Italy
| | - Stefano Bonassi
- San Raffaele University, Rome, Italy.,Clinical and Molecular Epidemiology, IRCCS San Raffaele Roma, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Headache and Neurosonology Unit, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
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Abstract
Headache disorders can produce recurrent, incapacitating pain. Migraine and cluster headache are notable for their ability to produce significant disability. The anatomy and physiology of headache disorders is fundamental to evolving treatment approaches and research priorities. Key concepts in headache mechanisms include activation and sensitization of trigeminovascular, brainstem, thalamic, and hypothalamic neurons; modulation of cortical brain regions; and activation of descending pain circuits. This review will examine the relevant anatomy of the trigeminal, brainstem, subcortical, and cortical brain regions and concepts related to the pathophysiology of migraine and cluster headache disorders.
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Affiliation(s)
- Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yulia Orlova
- Department of Neurology, University of Florida, Gainesville, Florida
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11
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Mail Gurkan Z, Tantik Pak A, Nacar Dogan S, Sengul Y. Microstructural changes of basal ganglia in migraine with restless legs syndrome: findings from a neuroimaging study. Sleep Biol Rhythms 2022; 20:361-369. [PMID: 38469422 PMCID: PMC10899932 DOI: 10.1007/s41105-022-00376-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 02/01/2022] [Indexed: 01/18/2023]
Abstract
In this study, it is planned to investigate the integrity of the basal ganglia structures in migraineurs with restless legs syndrome (RLS) to explore this relationship. In this study, 58 patients who were diagnosed migraine and 51 healthy controls (HCs) were included. Patients diagnosed with migraine were divided into two groups: Group I (migraine without RLS) and Group II (migraine with RLS). The integrity of basal ganglia was evaluated with region of interest diffusion tensor imaging method which allows us to assess microstructural changes of the tissue. The mean age of the patients was 35.98 ± 7.92 years, and the mean age of the HCs was 33.84 ± 11.06. 84.5% (n = 49) of the patients were female and 15.5% (n = 9) were male. 82.4% (n = 42) of the HCs were female, 17.6% (n = 9) were male. The number of the patients without RLS was 41 (Group I), and the number of the patients with RLS was 17 (Group II). When basal ganglia structures were compared between groups of the patients with and without RLS, the fractional anisotropy (FA) value of the left putamen differed (Group I: 0.30 ± 0.06 vs. Group II: 0.25 ± 0.7, p = 0.01). The significant relationship was found attack frequency and presence of RLS with left putamen FA values according to multiple regression analysis. It was determined in this study that the changes in the microstructure of putamen, one of the basal ganglia structures, may be associated with the presence of RLS in migraineurs.
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Affiliation(s)
- Zahide Mail Gurkan
- Neurology Department of Gaziosmanpasa Training and Research Hospital, Gaziosmanpasa, Istanbul, Turkey
| | - Aygul Tantik Pak
- Neurology Department of Gaziosmanpasa Training and Research Hospital, Gaziosmanpasa, Istanbul, Turkey
| | - Sebahat Nacar Dogan
- Radiology Department of Gaziosmanpasa Training and Research Hospital, Gaziosmanpasa, Istanbul, Turkey
| | - Yıldızhan Sengul
- Neurology Department of Gaziosmanpasa Training and Research Hospital, Gaziosmanpasa, Istanbul, Turkey
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12
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Zhao J, Shi W, Lu Y, Gao X, Wang A, Zhang S, Du Y, Wang Y, Li L. Alterations of monoamine neurotransmitters, HPA-axis hormones, and inflammation cytokines in reserpine-induced hyperalgesia and depression comorbidity rat model. BMC Psychiatry 2022; 22:419. [PMID: 35733107 PMCID: PMC9214971 DOI: 10.1186/s12888-022-04065-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/15/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pain and depression often occur simultaneously, but the mechanism of this condition is still unclear. METHODS The aim of this study was to examine the alterations of monoamine neurotransmitters, hypothalamic-pituitary-adrenal (HPA) axis hormones, and inflammation cytokines in hyperalgesia and depression comorbidities. The reserpine-induced "Sprague Dawley" (SD) rat models were used, and the concentrations of monoamine neurotransmitters serotonin (5-HT), norepinephrine (NE), dopamine (DA), and their metabolic products 5-hydroxyindoleacetic acid (5-HIAA), Homovanillic acid (HVA), 3,4-Dihydroxyphenylacetic acid (DOPAC) in raphe nucleus region were tested by High Performance Liquid Chromatography (HPLC). Serum levels of Adrenocorticotropic Hormone (ACTH), Cortisol (CORT), and inflammatory cytokines interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, IL-4, IL-10 were assessed by enzyme linked immunosorbent assay. RESULTS Repeated reserpine injection induced hyperalgesia and depressive behaviors with decreased sucrose preference and horizontal movement distance, and increased immobility time in forced swimming test. The concentrations of 5-HT and NE in raphe nucleus, and ACTH and CORT in serum were elevated in the model group. And the model group showed increases in serum IL-1β and IL-6, and decrease in serum IL-10. CONCLUSION More research in these areas is needed to understand the pathogenesis of the disease, so as to find more and better therapeutic targets.
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Affiliation(s)
- Jingjie Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China ,grid.24696.3f0000 0004 0369 153XDepartment of Integrated Traditional and Western Medicine, Capital Medical University, Beijing, 100050 China
| | - Wei Shi
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China ,grid.411609.b0000 0004 1758 4735Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, 100045 China
| | - Yujia Lu
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Xuesong Gao
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Anna Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Shan Zhang
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Yi Du
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Yongzhi Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050 China
| | - Li Li
- Department of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-an Road, Beijing, 100050, China. .,Department of Integrated Traditional and Western Medicine, Capital Medical University, Beijing, 100050, China.
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Syvertsen Mykland M, Uglem M, Petter Neverdahl J, Rystad Øie L, Wergeland Meisingset T, Dodick DW, Tronvik E, Engstrøm M, Sand T, Moe Omland P. Sleep restriction alters cortical inhibition in migraine: A transcranial magnetic stimulation study. Clin Neurophysiol 2022; 139:28-42. [DOI: 10.1016/j.clinph.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/22/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022]
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Vernieri F, Altamura C, Brunelli N, Costa CM, Aurilia C, Egeo G, Fofi L, Favoni V, Lovati C, Bertuzzo D, d'Onofrio F, Doretti A, Di Fiore P, Finocchi C, Schiano Di Cola F, Ranieri A, Colombo B, Bono F, Albanese M, Cevoli S, Barbanti P. Rapid response to galcanezumab and predictive factors in chronic migraine patients: A 3-month observational, longitudinal, cohort, multicenter, Italian real-life study. Eur J Neurol 2022; 29:1198-1208. [PMID: 34826192 DOI: 10.1111/ene.15197] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/18/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE A rapid response to preventive therapy is of pivotal importance in severely disabled patients with chronic migraine (CM) and diverse preventive treatment failures. This prospective, observational, multicenter real-life study aimed at investigating the effectiveness of galcanezumab in the first 3 months of treatment of CM patients at 14 Italian headache centers. METHODS All consecutive adult patients with CM diagnosis with the clinical indication for galcanezumab were considered. We collected patients' baseline characteristics, monthly headache days, monthly painkiller intake, migraine clinical characteristics, and disability scale scores during a 1-month run-in period (baseline) and the first 3 months of therapy. Possible predictive factors of treatment were considered. RESULTS A total of 156 patients (82.4% female, aged 47.3 ± 12.3 years) were enrolled. The 65 (41.7%) patients with a consecutive ≥50% response rate (RR) in the 3 months of therapy presented a lower body mass index (p = 0.004) and more frequently presented unilateral migraine pain (p = 0.002) and good response to triptans (p = 0.003). Persistent conversion from CM to episodic migraine was observed in 55.8% (87/156) of patients. They more frequently presented a good response to triptans (p = 0.003) and unilateral pain (p = 0.046). At baseline, 131 of 156 (83.9%) patients presented medication overuse (MO). Of these, 61.8% (81/131) no longer displayed MO consistently during the 3 months. These patients were more frequently responders to triptans (p = 0.002) and less frequently suffered from gastrointestinal comorbidity (p = 0.007). CONCLUSIONS Unilateral pain, good response to triptans, and normal weight may be associated with a persistent positive response in the first 3 months of therapy with galcanezumab in CM patients.
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Affiliation(s)
- Fabrizio Vernieri
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Claudia Altamura
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | | | - Cinzia Aurilia
- Headache and Pain Unit, San Raffaele Pisana, Scientific Institute for Research and Health Care, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, San Raffaele Pisana, Scientific Institute for Research and Health Care, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, San Raffaele Pisana, Scientific Institute for Research and Health Care, Rome, Italy
| | - Valentina Favoni
- Bologna Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
| | - Carlo Lovati
- Neurology Unit, Headache Center, L. Sacco University Hospital, Milan, Italy
| | | | | | - Alberto Doretti
- Department of Neurology, Stroke Unit and Laboratory of Neuroscience, Italian Auxological Institute, Scientific Institute for Research and Health Care, Milan, Italy
| | - Paola Di Fiore
- Headache Center, Neurology and Stroke Unit, S. Carlo Borromeo Hospital, Milan, Italy
| | - Cinzia Finocchi
- San Martino Polyclinic Hospital, Scientific Institute for Research and Health Care, Genoa, Italy
| | - Francesca Schiano Di Cola
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angelo Ranieri
- Headache Center, Neurology and Stroke Unit, A. Cardarelli Hospital, Naples, Italy
| | - Bruno Colombo
- San Raffaele Hospital, Scientific Institute for Research and Health Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, Mater Domini University Hospital, Catanzaro, Italy
| | - Maria Albanese
- Headache Center, Neurology Unit, Tor Vergata University Hospital, Rome, Italy.,Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Sabina Cevoli
- Bologna Institute of Neurological Sciences, Scientific Institute for Research and Health Care, Bologna, Italy
| | - Piero Barbanti
- Headache and Pain Unit, San Raffaele Pisana, Scientific Institute for Research and Health Care, Rome, Italy.,San Raffaele University, Rome, Italy
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Goetz A, McCormick S, Phillips R, Friedman D. CE: Diagnosing and Managing Migraine. Am J Nurs 2022; 122:32-43. [PMID: 34882585 DOI: 10.1097/01.naj.0000805640.82646.ac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Roughly 90% of the U.S. population will develop a headache within their lifetime, and headache disorders account for more disability-adjusted life-years than all other neurologic disorders combined. Among primary headache disorders, the two most common are tension-type headache and migraine, with migraine identified as the most disabling. Here, the authors describe the importance of differentiating primary and secondary headache disorders and discuss the pathophysiology; clinical assessment; and outpatient management of the debilitating migraine headache, summarizing both acute and prophylactic treatment strategies that can substantially reduce associated disability.
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Affiliation(s)
- Allene Goetz
- Allene Goetz is a board-certified clinical nurse specialist and Samantha McCormick is a board-certified physician assistant, both in the Headache and Facial Pain program in the Department of Neurology at UT Southwestern Medical Center, Dallas, TX. Rosemary Phillips is a triage nurse in the Department of Neurology and Deborah Friedman is a professor in the Departments of Neurology and Ophthalmology at UT Southwestern Medical Center. Contact author: Deborah Friedman, . The authors acknowledge Karen Lee-Roig for her artwork depicting her personal experience with migraine. Deborah Friedman serves on advisory boards for Allergan/AbbVie, Biohaven Pharmaceuticals, Lundbeck, Impel NeuroPharma, and Eli Lilly, and receives research support from Allergan/AbbVie and Eli Lilly. Lippincott Professional Development has identified and resolved all conflicts of interest concerning this educational activity. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise
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Togha M, Martami F, Jafari E, Ariyanfar S, Hashemi SM. The prevalence and characteristics of visceral autonomic symptoms among migraineurs: A population-based study. Cephalalgia 2021; 42:500-509. [PMID: 34786963 DOI: 10.1177/03331024211056849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is limited evidence about visceral autonomic symptoms in the different phases of migraine attack. We evaluated the prevalence of these symptoms in migraineurs before, during, and after headache attacks. In addition, the association between migraine characteristics and visceral autonomic symptoms was investigated. METHODS A total of 605 participants who met the entry criteria were enrolled prospectively in this cross-sectional study. Participants were 18-60 years old and met the ICHD-3 criteria for migraine with or without aura. Information on the migraine symptoms was gathered from all participants in face-to-face interviews. A structured questionnaire was used to evaluate the related symptoms before, during, and after attacks. Migraine features of frequency, duration, and severity were also assessed. RESULTS Considering all phases, the most commonly present visceral symptom was nausea (52.9%). About half of participants reported at least one visceral symptom before the onset of attacks. While, during and after attacks, 71% and 36% of participants reported such characteristics, respectively. Notably, the migraine headache in participants with visceral symptoms was longer during attacks compared to participants without them (24.4 ± 29.6 vs. 16.8 ± 19.8; P = 0.008). Additionally, subjects with positive visceral symptoms experienced more severe migraine attacks than participants without symptoms for both the premonitory (8 ± 1.7 vs. 7.6 ± 1.8; P = 0.02) and during-attack (8.01 ± 1.7 vs. 7.09 ± 1.9; P = 0.001) phases. CONCLUSION This study demonstrated that visceral symptoms were common in migraine sufferers not only during attacks but also in the premonitory and postdrome phases. Positive visceral symptoms were also associated with more burdensome headache attacks. Therefore, recognizing the phenotypic presentation of associated symptoms of migraine, especially during the pre-attack phase, could aid in early implementation of optimal management.
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Affiliation(s)
- Mansoureh Togha
- Headache Department, 48439Tehran University of Medical Sciences, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Martami
- School of Nutritional Sciences and Dietetics, 48439Tehran University of Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Jafari
- Headache Department, 48439Tehran University of Medical Sciences, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shadi Ariyanfar
- Department of Clinical Nutrition and Dietetics, 556492Shahid Beheshti University of Medical Sciences, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedeh Melika Hashemi
- Headache Department, 48439Tehran University of Medical Sciences, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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Silvestro M, Tessitore A, Scotto di Clemente F, Battista G, Tedeschi G, Russo A. Refractory migraine profile in CGRP-monoclonal antibodies scenario. Acta Neurol Scand 2021; 144:325-333. [PMID: 34019304 PMCID: PMC8453754 DOI: 10.1111/ane.13472] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/25/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022]
Abstract
Objective Refractory migraine (Ref‐M) represents a conundrum that headache experts have to face with. We aim to investigate whether a peculiar profile may characterize patients with Ref‐M according to 2020 European Headache Federation criteria. Furthermore, to substantiate a dysfunctional dopaminergic pathway involvement in these patients, we explored the effectiveness of olanzapine. Materials & Methods Eighty‐four patients (fitting previous Ref‐M criteria of the 2014) were treated with erenumab for six months. Differences between clinical and demographic features of responder (Ref‐M according to 2014 criteria) and not‐responder (Ref‐M according to 2020 criteria) patients to CGRP‐mAbs were investigated and their predictive values assessed. In fifteen patients with Ref‐M not responders to CGRP‐mAbs, olanzapine was administered (5 mg/die) for 3 months and frequency and pain intensity of migraine attacks were estimated. Results Patients with Ref‐M not responsive to CGRP‐mAbs (29/84) when compared with Ref‐M responsive to CGRP‐mAbs showed higher baseline frequency of migraine attacks, medication overuse and pain catastrophizing scale (PCS) scores. Logistic regression analyses showed that frequency of attacks, medication overuse and PCS score represent independent negative predictors of CGRP‐mAbs response. A ≥50% reduction of headache days/month was observed after olanzapine treatment in 67% of patients with Ref‐M not responsive to CGRP‐mAbs. Conclusions We outline that higher frequency of migraine attacks, medication overuse and pain catastrophizing characterize patients with Ref‐M not responsive to CGRP‐mAbs. In this frame, olanzapine effectiveness on frequency and pain intensity of migraine attacks supports the hypothesis that migraine refractoriness may be subtended by a prominent involvement of the dopaminergic pathway.
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Affiliation(s)
- Marcello Silvestro
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
| | - Alessandro Tessitore
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
| | - Fabrizio Scotto di Clemente
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
| | - Giorgia Battista
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
| | - Gioacchino Tedeschi
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
| | - Antonio Russo
- Headache Centre Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences University of Campania “Luigi Vanvitelli” Napoli Italy
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Barbanti P, Aurilia C, Cevoli S, Egeo G, Fofi L, Messina R, Salerno A, Torelli P, Albanese M, Carnevale A, Bono F, D'Amico D, Filippi M, Altamura C, Vernieri F. Long-term (48 weeks) effectiveness, safety, and tolerability of erenumab in the prevention of high-frequency episodic and chronic migraine in a real world: Results of the EARLY 2 study. Headache 2021; 61:1351-1363. [PMID: 34309862 DOI: 10.1111/head.14194] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the long-term effectiveness, safety, and tolerability of erenumab in a real-world migraine population, looking for putative predictors of responsiveness. BACKGROUND Erenumab proved to be effective, safe, and well tolerated in the prevention of episodic migraine (EM) and chronic migraine (CM) in long-term extension studies of double-blind, placebo-controlled trials in patients with no more than two (EM) or three (CM) prior preventive treatment failures. METHODS A 48-week, multicenter, longitudinal cohort real-life study was conducted at 15 headache centers across eight Italian regions between December 20, 2018 and July 31, 2020. We considered all consecutive patients with high-frequency episodic migraine (HFEM) or CM aged 18-65 years. Each patient was treated with erenumab 70 mg, administered monthly. The dose was switched to 140 mg in nonresponders and in responders who had become nonresponders for at least 4 weeks. Change in monthly migraine days (MMDs) or monthly headache days (MHDs) at Weeks 45-48 compared with baseline was the primary efficacy endpoint. Secondary endpoints encompassed variation in monthly analgesic intake, achievement of a ≥50%, ≥75%, or 100% reduction in migraine or headache days, and any change in the Visual Analogue Scale (VAS) and Headache Impact Test-6 scores (HIT-6) during the same time interval. RESULTS A total of 242 patients with migraine received at least one dose of erenumab 70 mg and were considered for safety analysis, whereas 221 received a monthly erenumab dose for ≥48 weeks and were included in the effectiveness and safety analysis set. All patients had previously been treated unsuccessfully with ≥3 migraine-preventive medication classes. From baseline to Weeks 45-48, erenumab treatment reduced MMD by 4.3 ± 5.3 (mean ± SD) in patients with HFEM, and MHD by 12.8 ± 8.9 (mean ± SD) in subjects with CM. VAS and HIT-6 scores were decreased by 1.8 ± 1.9 (mean ± SD) and 12.3 ± 11 (mean ± SD) in HFEM, and by 3.0 ± 2.2 (mean ± SD) and 13.1 ± 11.2 (mean ± SD) in CM. Median monthly analgesic intake passed from 11.0 (interquartile range [IQR] 10.0-13.0) to 5 (IQR 2.0-8.0) in HFEM and from 20.0 (IQR 15.0-30.0) to 6.0 (IQR 3.8-10.0) in CM. The ≥50% responders were 56.1% (32/57) in HFEM and 75.6% (124/164) in CM; ≥75% responders were 31.6% (18/57) and 44.5% (73/164); and 100% responders were 8.8% (5/57) and 1.2% (2/164), respectively. At Week 48, 83.6% (137/164) of patients with CM had reverted to EM. Erenumab was safe and well tolerated. Responsiveness to erenumab was positively associated with cutaneous allodynia (OR: 5.44, 95% CI: 1.52-19.41; p = 0.009) in HFEM. In patients with CM, ≥50% responsiveness was positively associated with male sex (OR: 2.99, 95% CI: 1.03-8.7; p = 0.044) and baseline migraine frequency (OR: 1.12, 95% CI: 1.05-1.20; p = 0.001) and negatively associated with psychiatric comorbidities (OR: 0.37, 95% CI: 0.15-0.87; p = 0.023) and prior treatment failures (OR: 0.77, 95% CI: 0.64-0.92; p = 0.004). CONCLUSIONS Long-term (48-week) erenumab treatment provides sustained effectiveness, safety, and tolerability in real-life patients with HFEM or CM with ≥3 prior preventive treatment failures. The dose of 140 mg was required in most patients along the study and should be taken into consideration as the starting dose. Allodynia (in HFEM), male sex, and baseline migraine frequency (in CM) might represent positive responsiveness predictors. Conversely, psychiatric comorbidities and multiple prior preventive treatment failures could be negative predictors in patients with CM.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Roberta Messina
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Paola Torelli
- Unit of Neurology, Department of Medicine and Surgery, Headache Center, University of Parma, Parma, Italy
| | - Maria Albanese
- Neurophysiopathology Unit, Headache Center, University Hospital of Rome "TorVergata", Rome, Italy
| | | | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Domenico D'Amico
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Claudia Altamura
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Abstract
Migraine is a complex genetic brain disorder with an intricate pathogenesis and polymorphous clinical presentations, particularly in children. In this Perspective, we describe the different phenotypes of migraine in children, including conditions that have been referred to in the International Classification of Headache Disorders as "syndromes that may be related to migraine''. Evidence is presented for the integration of abdominal migraine, cyclical vomiting syndrome, benign paroxysmal vertigo, benign paroxysmal torticollis and infantile colic into the unified diagnosis of 'childhood migraine syndrome' on the basis of clinical and epidemiological characteristics, and shared inheritance. In our opinion, such integration will guide clinicians from specialities other than neurology to consider migraine in the assessment of children with these disorders, as well as stimulate research into the genetics, pathophysiology and clinical features of all disorders within the syndrome. A diagnosis of childhood migraine syndrome would also enable patients to benefit from inclusion in clinical trials of old and new migraine treatments, thus potentially increasing the number of treatment options available.
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Karsan N, Goadsby PJ. Migraine Is More Than Just Headache: Is the Link to Chronic Fatigue and Mood Disorders Simply Due to Shared Biological Systems? Front Hum Neurosci 2021; 15:646692. [PMID: 34149377 PMCID: PMC8209296 DOI: 10.3389/fnhum.2021.646692] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/26/2021] [Indexed: 12/12/2022] Open
Abstract
Migraine is a symptomatically heterogeneous condition, of which headache is just one manifestation. Migraine is a disorder of altered sensory thresholding, with hypersensitivity among sufferers to sensory input. Advances in functional neuroimaging have highlighted that several brain areas are involved even prior to pain onset. Clinically, patients can experience symptoms hours to days prior to migraine pain, which can warn of impending headache. These symptoms can include mood and cognitive change, fatigue, and neck discomfort. Some epidemiological studies have suggested that migraine is associated in a bidirectional fashion with other disorders, such as mood disorders and chronic fatigue, as well as with other pain conditions such as fibromyalgia. This review will focus on the literature surrounding alterations in fatigue, mood, and cognition in particular, in association with migraine, and the suggested links to disorders such as chronic fatigue syndrome and depression. We hypothesize that migraine should be considered a neural disorder of brain function, in which alterations in aminergic networks integrating the limbic system with the sensory and homeostatic systems occur early and persist after headache resolution and perhaps interictally. The associations with some of these other disorders may allude to the inherent sensory sensitivity of the migraine brain and shared neurobiology and neurotransmitter systems rather than true co-morbidity.
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Affiliation(s)
- Nazia Karsan
- Headache Group, Wolfson Centre for Age-Related Diseases, Division of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom
| | - Peter J Goadsby
- Headache Group, Wolfson Centre for Age-Related Diseases, Division of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, London, United Kingdom.,Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
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21
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Waliszewska-Prosół M, Nowakowska-Kotas M, Chojdak-Łukasiewicz J, Budrewicz S. Migraine and Sleep-An Unexplained Association? Int J Mol Sci 2021; 22:ijms22115539. [PMID: 34073933 PMCID: PMC8197397 DOI: 10.3390/ijms22115539] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 01/14/2023] Open
Abstract
Migraine and sleep disorders are common chronic diseases in the general population, with significant negative social and economic impacts. The association between both of these phenomena has been observed by clinicians for years and is confirmed by many epidemiological studies. Despite this, the nature of this relationship is still not fully understood. In recent years, there has been rapid progress in understanding the common anatomical structures of and pathogenetic mechanism between sleep and migraine. Based on a literature review, the authors present the current view on this topic as well as ongoing research in this field, with reference to the key points of the biochemical and neurophysiological processes responsible for both these disorders. In the future, a better understanding of these mechanisms will significantly expand the range of treatment options.
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22
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Relationship between non-headache symptoms and right to left shunt in episodic migraine. A single-center cross-sectional study. J Clin Neurosci 2021; 86:38-44. [PMID: 33775344 DOI: 10.1016/j.jocn.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 11/03/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
The relationship between right to left shunt (RLS) and non-headache symptoms (NHS) in episodic migraine is unknown. This study aimed to investigate the incidence and classification of RLS in episodic migraineurs, calculate the occurrence rate of NHS, and analyze the associations between RLS and NHS. We consecutively recruited 204 episodic migraine patients. Contrast-enhanced transcranial doppler was adopted to screen RLS. Structured questionnaire via face-to-face survey was conducted to collect clinical data. A total of 172 episodic migraineurs were included in the final analysis, of which 20 cases were migraine with aura. The positive rate of RLS was 47.1%, of which 50 cases (29.0%) had small shunt (Grade 1) and 31 cases (18.1%) had mid-large shunt (Grade 2-4). The most common NHS was nausea (115 (66.9%)), followed by headache aggravation with physical activity (96 (55.8%)), dizziness (93 (54.1%)), vomiting (77 (44.8%)) and phonophobia (74 (43.0%)). Yawning was more common in Grade 2-4 group than Grade 0 group (p = 0.012), while no statistical differences among other groups. Grade 2-4 group had a higher rate of headache aggravation with physical activity than grade 0 group (p = 0.008). Binary logistic regression analysis showed that yawning at premonitory phase, headache aggravation with physical activity and cranial autonomic symptoms during attack are independent predictors of RLS. In conclusion, yawning and headache aggravation with physical activity are more common in migraine patients with RLS. Besides aura, particular NHS may also serve as indicators for screening RLS in episodic migraineurs.
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23
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Barbanti P, Aurilia C, Egeo G, Fofi L, Cevoli S, Colombo B, Filippi M, Frediani F, Bono F, Grazzi L, Salerno A, Mercuri B, Carnevale A, Altamura C, Vernieri F. Erenumab in the prevention of high-frequency episodic and chronic migraine: Erenumab in Real Life in Italy (EARLY), the first Italian multicenter, prospective real-life study. Headache 2020; 61:363-372. [PMID: 33337544 DOI: 10.1111/head.14032] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the effectiveness, safety, and tolerability of erenumab in a real-life migraine population, while trying to identify responsiveness predictors. BACKGROUND Erenumab is a fully human Ig-2 monoclonal antibody blocking the calcitonin gene-related peptide receptor, indicated for migraine prophylaxis. Phase II and III trials demonstrated that erenumab is effective, safe, and well tolerated in the prevention of episodic and chronic migraine (CM), showing an early onset of action. METHODS This is a multicenter, prospective, cohort, and real-life study. We considered for enrolment all consecutive patients aged 18-65 affected by high-frequency episodic migraine (HFEM) or CM, with or without medication overuse, visited at nine Italian Headache Centers from December 20, 2018 to September 30, 2019. Each patient was treated with erenumab 70 mg, administered subcutaneously every 4 weeks. Treatment duration was planned to last from 6 to 12 months, depending on the patient's response. The primary endpoint was the change in monthly migraine days (MMDs) at weeks 9-12 compared to baseline. Secondary endpoints included changes in monthly analgesics intake, ≥50%, ≥75%, and 100% responder rates and any variation in the Visual Analog Scale (VAS) and Headache Impact Test scores (HIT). RESULTS In total, 372 migraine patients were treated with at least one dose of erenumab 70 mg. At weeks 9-12, erenumab decreased MMDs by 4.5 ± 4.1 days (mean ± SD) in patients with HFEM and by 9.3 ± 9.1 (mean ± SD) days in those with CM compared to baseline. At weeks 9-12 VAS score was reduced by 1.9 ± 1.9 (mean ± SD), HIT score by 10.7 ± 8.8 (mean ± SD), and median monthly analgesics intake passed from 12.0 (interquartile range [IQR] 10.0-14.0) to 5.0 (IQR 3.0-7.0) in HFEM. In CM patients, VAS was reduced by 1.7 ± 2.0 (mean ± SD), HIT by 9.7 ± 10.4 (mean ± SD), and median monthly analgesics intake passed from 20.0 (IQR 15.0-30.0) to 8.0 (IQR 5.0-15.0). At week 12, ≥50% responders were 60/101 (59.4%) for HFEM and 146/263 (55.5%) for CM, ≥75% responders were 17/101 (16.8%) and 59/263 (22.4%) and 100% responders 1/101 (1.0%) and 3/263 (1.1%), respectively. Erenumab responsiveness in HFEM was positively associated with unilateral pain localization (OR: 3.03, 95% CI: 1.24-7.40; p = 0.015), whereas in CM responsiveness was positively associated with and baseline migraine frequency (OR: 1.06, 95% CI:1.02-1.11; p = 0.031), dopaminergic symptoms (OR: 2.01, 95% CI: 1.14-3.52; p = 0.015), and negatively associated with psychiatric comorbidities (OR: 0.43, 95% CI: 0.20-0.93; p = 0.003). CONCLUSIONS Erenumab 70 mg is effective, safe, and well tolerated in real life. Easily obtainable clinical features might be of help in predicting patient's responsiveness.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Luisa Fofi
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - Bruno Colombo
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Francesco Bono
- Center for Headache and Intracranial Pressure Disorders, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Licia Grazzi
- Neuroalgology Unit, Headache Center Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | | | | | | | - Claudia Altamura
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Policlinico Universitario Campus Bio-Medico, Rome, Italy
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24
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Duan J, Yang R, Lu W, Zhao L, Hu S, Hu C. Comorbid Bipolar Disorder and Migraine: From Mechanisms to Treatment. Front Psychiatry 2020; 11:560138. [PMID: 33505322 PMCID: PMC7829298 DOI: 10.3389/fpsyt.2020.560138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022] Open
Abstract
Bipolar disorder (BD) is a severe psychiatric disorder characterized by recurrent episodes of manic/hypomanic or depressive symptoms and euthymic periods, with some patients suffering a gradual deterioration of illness and consequent cognitive deficits during the late stage. Migraine is a disease generally without abnormal medical examinations, neurological examinations or laboratory studies, and the diagnosis is made based on the retrospective demonstration of headache features and groupings of disease-associated symptoms. The epidemiology of comorbid BD and migraine is high and it is obligatory to find effective treatments to improve the prognosis. Recent investigations demonstrated that the close relationship between BD and migraine significantly increased the rapid cycling rates of both BD and migraine in patients. Although the detailed mechanism is complex and largely unclear in comorbid BD and migrain, genetic factors, neurotransmitters, altered signaling pathways, disturbances of inflammatory cytokines, and mitochondrial dysfunction are risk factors of BD and migraine. Particularly these two diseases share some overlapping mechanisms according to previous studies. To this end, we call for further investigations of the potential mechanisms, and more efforts are underway to improve the treatment of people with comorbid BD and migraine. In this review, we provide an overview of the potential mechanisms in patients with BD or migraine and we further discuss the treatment strategies for comorbid BD and migraine and it is obligatory to find effective treatments to improve the prognosis. This work will provide insights for us to know more about the mechanisms of comorbid BD and migraine, provides new therapeutic targets for the treatment and give clinicians some guidance for more appropriate and beneficial treatment.
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Affiliation(s)
- Jinfeng Duan
- Key Laboratory of Mental Disorder's Management of Zhejiang Province, Department of Psychiatry, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Rongmei Yang
- Department of Psychogeriatrics, Hangzhou Seventh People's Hospital, Hangzhou, China
| | - Wenwen Lu
- Department of Traditional Chinese Medicine, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Lingfei Zhao
- Key Laboratory of Kidney Disease Prevention and Control Technology, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Shaohua Hu
- Key Laboratory of Mental Disorder's Management of Zhejiang Province, Department of Psychiatry, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chenxia Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, School of Medicine, First Affiliated Hospital, Zhejiang University, Hangzhou, China
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